Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy For Morbid Obesity: A Tertiary Care Experience and Design of A Management Algorithm

5/16/2019 Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and
ence and design of a management algorith…

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ORIGINAL ARTICLE
Year : 2016 | Volume : 12 | Issue : 4 | Page : 342349
Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A
tertiary care experience and design of a management algorithm

Palanivelu Praveenraj1, Rachel M Gomes1, Saravana Kumar1, Palanisamy Senthilnathan2, Ramakrishnan Parthasarathi2, Subbiah
Rajapandian2, Chinnusamy Palanivelu2,

1 Department of Bariatric Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India

2 Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India

Correspondence Address:
Palanivelu Praveenraj

Department of Bariatric Surgery, 45, Pankaja Mill Road, Gem Hospital and Research Centre, Coimbatore 641 045, Tamil Nadu
India

Abstract

Background: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed 'standalone' bariatric
procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim
of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity
at our institution. Patients and Methods: From February 2008 to 2014, 650 patients with different degrees of
morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study.
Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of
leak, investigations performed, treatment given and time of closure of all leaks were analysed. Results: Among the
650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was
performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ±
5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were
late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably
before or after resurgery. Resurgery was performed in all and included stapled fistula excision (resleeve), suture
repair only or with conversion to rouxenY gastric bypass or fistula jujenostomy. There was no mortality.
Conclusion: Leakage closure time may be shorter with intervention than expectant management. Sequence and
choice of endoscopic oesophageal stenting and/or surgical reintervention should be individualized according to
clinical presentation.

How to cite this article:

Praveenraj P, Gomes RM, Kumar S, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C. Management of
gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a
management algorithm.J Min Access Surg 2016;12:342349

How to cite this URL:

Praveenraj P, Gomes RM, Kumar S, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C. Management of
gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a
management algorithm. J Min Access Surg [serial online] 2016 [cited 2019 May 16 ];12:342349
Available from: http://www.journalofmas.com/text.asp?2016/12/4/342/181285

Full Text

Introduction

Laparoscopic sleeve gastrectomy (LSG) is emerging to be one of the commonly performed bariatric procedures
worldwide for patients with different degrees of obesity. This restrictive procedure has several advantages. It is
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5/16/2019 Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorith…
technically simpler to perform without the need of an anastomosis. It induces a reduction in ghrelin causing appetite
suppression, which adds to the effect of restriction.[1],[2],[3],[4] It has been reported to have a lower morbidity and
mortality rate in comparison to RouxenY gastric bypass or biliopancreatic diversion with or without duodenal switch.
[5] It can be performed concomitantly with other procedures.[6]

LSG can be associated with three significant complications, which include staple line gastric bleeding, staple line
gastric leaks and gastric strictures. Of these, a gastric leak after sleeve gastrectomy is associated with significant and
prolonged morbidity, remaining one of the most feared complications. A gastric leak can present as peritonitis,
abscesses, cutaneous or other fistulas, sepsis, organ failure and even death. Fortunately it is an infrequent
complication of LSG. However, as a consequence, the management of such patients cannot be clearly recommended.
Analysing patients with this problem can help define a clinical approach for management and possible preventive
measures.

The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for
morbid obesity at our institution.

Patients and Methods

Study population

From February 2008 to 2014, 650 patients with morbid obesity with a mean body mass index of 44.64 ± 9.01 kg/m 2
underwent LSG. Among them, all those diagnosed with a gastric leak were included in the study. Patients referred to
our institution with gastric leak after LSG were also included.

Surgical technique of laparoscopic sleeve gastrectomy

After a closed 16 mmHg pneumoperitoneum with a Veress needle, five trocars were inserted: A 5mm subxiphoid
trocar (served as liver retractor); a 12mm right upper quadrant trocar (served as a working port, served to fire the
endoGIA stapler and served to remove the specimen); a 10mm supraumbilical trocar (served as camera port); a 5
mm left upper quadrant trocar (served as another working channel); and a 5mm left subcostal anterior axillary line
trocar (served for counter retraction). LSG was performed by dividing the greater omentum of the greater curvature
and the short gastric and fundal attachments using a Harmonic Ace device (Ethicon EndoSurgery, Cincinnati, OH,
USA) or a Ligasure device (Covidien Ltd, Norwalk, Connecticut, USA), beginning 45 cm proximal to the pylorus. Once
this was completed, a 36Fr bougie was introduced by the anaesthesiologist into the stomach, and advanced along
the lesser curvature into the pyloric channel. An endoGIA stapler (Echelon: 60mm stapling; Ethicon EndSurgery,
Cincinnati, OH, USA) was introduced through the 12mm port, which was located at the right quadrant, to begin the
gastric tubulisation by division of the antrum 45 cm proximal to the pylorus followed by serial firing of linear staplers
resulting in a small gastric tubular pouch. Reinforcement was not routinely performed. To determine leakage, flow
was transiently blocked into the duodenum with bowel forceps at the pyloric channel after instilling saline in the
abdominal cavity and an air test was performed by insufflating air through the ryle's tube inserted in the gastric
pouch. The resected specimen was removed through the 12mm port at the right upper abdominal quadrant. Drains
were not routinely placed.

Postoperative radiological screening

In all patients, a radiological evaluation was performed on the first postoperative day using diluted GASTROGRAFIN ®
Oral Solution (diatrizoate meglumine/diatrizoate sodium). While standing, the patient swallowed 100 mL of solution,
and the characteristics of the tubular stomach (i.e., size, emptying and presence or absence of leak or stricture) were
evaluated with fluoroscopy.

Classification of gastric leaks

We used the classifications proposed by Csendes et al. and Burgos et al. of gastric leaks based on the time of
appearance after surgery, clinical severity and location of leaks.[7],[8],[9]

Based on clinical presentation, gastric leaks were classified as follows:

Type I (Subclinical): Presence of leakage without early septic complications corresponding to drainage through a
fistulous track and/or without generalised dissemination to the pleural or abdominal cavity with or without the
appearance of contrast medium in any of the abdominal drains. Type II (Clinical): Presence of leakage with early
septic complications corresponding to drainage by an irregular pathway (no wellformed fistulous tract) and a more
generalised dissemination into the pleural or abdominal cavity with or without appearance of contrast medium in any
of the abdominal drains.

Based on the time when the leaks presented, they were classified as follows:

Early (leaks appearing 13 days after surgery). Intermediate (leaks appearing 47 days after surgery). Late (leaks
appearing ≥8 days after surgery).

Data collection

In all patients with the presence of a gastric leak, the information collected included patient demographics,
anthropometrics, details of comorbidities, operative and perioperative data, time of presentation, site of leak, details
of methods used to detect and manage the leaks, time of closure, interval between surgery and detection and interval
between detection and leak closure.

Results

Individual case summaries

Patient 1 (Type 2, intermediate gastric leak just beyond oesophagogastric junction treated with laparoscopic
drainage, fistula exclusion with a long, fully covered oesophageal stent and laparoscopic suturing of gastric fistula)

Case details: A 52yearold male, at an outside hospital presented with sepsis on the sixth postoperative day after
LSG. Relaparoscopy revealed a fistula just beyond the oesophagogastric junction, which was drained. Fistula was
stented with a NitiS™ Mega™ oesophageal stent (Taewoong Medical, Seoul, Korea), complicated by bleeding on the
fifth postoperative day from stent erosion into the duodenal mucosa needing removal. He was referred to us at 3
months after LSG with a controlled gastric fistula. Endoscopy revealed a small opening just beyond the oesophago
gastric junction. Contrastenhanced computed tomography (CECT) of the abdomen revealed minimal leak from the
oesophagogastric junction within a walledoff cavity. The patient did not gave consent for restenting. Re
laparoscopy with closure of fistulous opening in two layers with feeding jejunostomy was performed. In 72 h, there
was a leak again with the same output as before. Drainage gradually decreased and stopped 6 weeks postoperatively
with the absence of a leak on imaging. The patient was diagnosed on the sixth postoperative day and the time till the
fistula closure was 5.5 months.

Patient 2 [Type 2, intermediate gastric leak, just beyond oesophagogastric junction and at midsleeve, treated with
laparoscopic drainage, fistula jujenostomy and stapled excision of gastric fistula (resleeve)]

Case details: A 52yearold woman, with a body mass index (BMI) of 48 kg/m 2 without comorbidities at an outside
hospital presented on the seventh postoperative day with sepsis after LSG. Laparotomy revealed a fistula (details not
available) and drainage with feeding jujenostomy was performed. Endoscopy revealed narrowing at the incisura,
which was dilated. Postoperatively a gastrocutaneous fistula developed and was treated conservatively. She was
referred to us at 4 months after LSG with a controlled gastrocutaneous fistula through the middle of a midline
laparotomy scar. CECT scan showed a fistula from midbody stomach leading to the skin through a wellformed fistula
tract [Figure 1]a. Endoscopy revealed a large opening over the anterior gastric wall at midbody with narrowing at the
incisura. Relaparotomy revealed a cutaneous fistulous opening arising from a midbody gastric fistula [Figure 1]b
and [Figure 1]c. A sidetoside fistula loop gastrojujenostomy was performed [Figure 1]d. Postoperatively a small
bile leak developed from the laparotomy wound 1 month later. Endoscopy revealed a fistula just beyond the
oesophagogastric junction, probably a missed sealed fistula. After 8 weeks, relaparotomy with excision of the fistula
site with a linear stapler (resleeve) and suture reinforcement was performed. Loop gastrojujenostomy was
converted to a RouxenY configuration. The leak settled postoperatively with insignificant drain output and absence
of a leak on imaging. The patient had a poor general condition, improved gradually and was discharged from the
hospital 1 month later. The patient was diagnosed on the sixth postoperative day and the time from diagnosis to
fistula closure was 9 months.{Figure 1}

Patient 3 (Type 2, late leak just beyond oesophagogastric junction, treated with laparoscopic drainage, exclusion
with covered, selfexpanding metallic stent and laparoscopic suturing of fistula site with conversion to RouxenY
gastric bypass)

Case details: An 18yearold woman with a BMI of 44.68 kg/m 2 with hypothyroidism and polycystic ovarian disease
underwent LSG at our institution. Routine air leak test and gastrografin study showed no leak. She was readmitted on
postoperative day 15 with fever, chills, leucocytosis and abdominal pain. Abdominal ultrasound was normal. A CECT
scan performed because of high suspicion showed a 5 × 6.2 cm collection in the left subdiaphragmatic region with air
but no leak of contrast [Figure 2]a. Endoscopy did not reveal any fistula. At diagnostic laparoscopy, the abscess was
drained but no obvious fistula was noted and the air leak test was negative. In 48 h, an obvious leak of saliva was
noted in the drainage. Repeat imaging revealed a leak just beyond oesophagogastric junction. At relaparoscopy, a
small fistulous opening was identified at the oesophagogastric junction closed by suturing of the defect in two layers
[Figure 2]b. Concomitant RouxenY bypass was performed to decompress the stomach to aid healing. An antecolic,
100cm RouxenY limb was anastomosed endtoside after dividing across the sleeve to create a gastric pouch
[Figure 2]c and [Figure 2]d. A NitiS™ Beta™ oesophageal stent (Taewoong Medical, Seoul, Korea) was also placed at
the site of the sutured fistula repair. A feeding jujenostomy was performed. Drainage of the fistula decreased
postoperatively to an insignificant drain output and absence of a leak on imaging in 12 days. After 7 weeks, the stent
was removed. The patient was diagnosed on the 15th postoperative day and the time from diagnosis to fistula closure
was 1 month.{Figure 2}

Patient 4 [Type 1, early leak, just beyond oesophagogastric junction with staple line bleed treated with evacuation of
haematoma and stapled excision of the fistula site (resleeve)]

Case details: A 53yearold male with a BMI of 39.5 m 2 with type 2 diabetes mellitus, systemic hypertension,
dyslipidemia and gout underwent a LSG at our institution, Intraoperative air leak test was negative. Postoperative
gastrografin swallow revealed a doubtful leak. The patient had mild persistent tachycardia and low haemoglobin. A
CECT scan showed evidence of 10 × 8 cm subdiaphragmatic collection suggestive of a haematoma with a small leak
of contrast from the most proximal end of the staple line within the haematoma [Figure 3]a. The patient was re
explored and the haematoma was evacuated [Figure 3]b. The air leak test did not reveal any obvious site of leak. The
stomach just beyond the oesophagogastric junction was resleeved with a linear stapler [Figure 3]c. The site of
bleeding was identified and controlled [Figure 3]d. The entire staple line was reinforced with sutures and a drain
placed next to the staple line. Drainage amount decreased to a minimum by 5 days and was removed. The patient
was diagnosed with a sleeve leak on the first postoperative day and the time from diagnosis to fistula closure was 48
h.{Figure 3}

Patient 5 (Type 1, late leak just beyond oesophagogastric junction forming a gastrobronchial fistula, treated with
fistula exclusion with long covered selfexpanding metallic oesophageal stent and laparoscopic suturing of the fistula
site with conversion to RouxenY gastric bypass.)

Case details: A 53yearold woman with a BMI of 50.2 underwent LSG at our institution. She underwent regular
followup and had no complaints with a 7 months percentage of excess weight loss of 55%. At 7 months, she
presented with fever and cough and investigation revealed a left lower lobe consolidation. Ultrasound imaging of the
abdomen was normal. She was treated conservatively. The same however, recurred in 1 month. A CECT performed
revealed patchy consolidation of the left posterior basal segment with mild left pleural effusion, two small left sub
diaphragmatic collections with air pockets, with leak of oral contrast within the subdiaphragmatic collections draining
to a bronchus in left posterobasal segment [Figure 4]a. Endoscopy performed revealed a fistulous opening just
beyond the oesophagogastric junction. The patient was stented with a NitiS™ Mega™ oesophageal stent (Taewoong
Medical, Seoul, Korea), which did not lead to resolution of the leak after a trial of 6 weeks after which it was removed.
She then underwent diagnostic laparoscopy with disconnection of the fistulous tract and suturing of the fistulous
opening on the sleeve [Figure 4]b. Simultaneous RouxenY bypass was performed after creating a pouch by dividing
the sleeve across for decompression to augment healing [Figure 4]c and [Figure 4]d. She had an uneventful
postoperative course and was discharged in 5 days. The patient was diagnosed 7 months postoperatively with a
gastric sleeve leak and the time from diagnosis to fistula closure was 2 months.{Figure 4}

Summary of results

To summarise, among 650 patients who underwent LSG from February 2008 to 2014, 3 (0.46%) developed a gastric
leak. Two patients were referred with a gastric leak after LSG was performed at another institution. These patients
comprised three females and two males, with a mean age of 45.60 ± 15.43 years (range 18 to 53) and mean BMI of
44.79 ± 5.35.

Patients with gastric leak presented with abdominal pain, fever, tachycardia, cough and pneumonia. Gastric leak was
diagnosed at variable times ranging within 24 h to 7 months after surgery. One was an early leak (case 4), two were
intermediate leaks (cases 1 and 2) and two were late leaks (cases 3 and 5). One patient had a type I gastric leak
(case 5) and four patients had a type II gastric leak (cases 1, 2, 3 and 4). Patients with gastric leak were detected
early with persistent tachycardia (case 4) or intermediate/late wherein they were well initially and then presented
with fever, abdominal pain, cough and/or sepsis and were found to have subdiaphragmatic collections/leaks (cases
1, 2, 3 and 5). The earliest symptom was tachycardia in patients with early leak, whereas fever was the earliest
symptom in patients with intermediate/late leaks. There was no mortality in this series.

Intraoperative air leak tests were negative at the index surgery in the one early and one intermediate leak case
(cases 3 and 4) but was useful in detecting the site of leak in the one patient with a late leak (case 5) operated at our
institution. Postoperative contrast swallow tests with gastrografin on postoperative day 1 evidenced leak in only one
patient with an early leak (case 4). Gastric leak was located at the proximal third of great curvature in all five patients
and also in the midbody in one patient (case 2), probably a complication of endoscopic dilatation of an early stricture
at the incisura.

One type I early leak with a staple line bleed was explored within 48 h with evacuation of haematoma and underwent
resleeve of proximal new greater curve with suture reinforcement (case 4). The other type I leak (late leak/chronic
fistula) underwent suturing of the fistula site with conversion to RouxenY bypass after a prior failed attempt of a 6
week stenting.

All type II leaks needed diagnostic lavage and drainage. Pigtail drainage was not considered suitable as an initial
management due to the retrogastric location of the abscess. One intermediate leak (type II leak) underwent fistula
closure and simultaneous conversion to RouxenY bypass with a NitiS™ Beta™ oesophageal stent (Taewoong
Medical, Seoul, Korea) over the sutured closure. One case of intermediate leak (type II leak) underwent stenting with
a NitiS™ Mega™ oesophageal stent (Taewoong Medical, Seoul, Korea), which was complicated by bleeding and
needed removal. He then underwent surgery with only resuturing at the fistula site, which failed. He recovered after
prolonged conservative treatment. Lastly, one case of intermediate leak (type II leak) fistula underwent fistulo
jejunostomy for a midbody fistula with distal stricture. She needed reexploration for a missed proximal leak. At re
laparotomy, the site of leak was mobilised and excised with a linear stapler and the suture was reinforced and the
loop fistulojejunostomy was also converted to a RouxenY configuration. Nutrition was maintained by parenteral
nutrition, feeding jejunostomy and nasojejunal tubes in four patients with early /intermediate leaks. In the patient
with a chronic fistula, nutrition was maintained orally.

Discussion

LSG is a popular restrictive bariatric procedure indicated as a standalone operation or as the first stage of the
laparoscopic duodenal switch.[1],[2],[3] In this series, we analysed cases presenting with gastric leak among a
consecutive series of 650 LSGs performed as a standalone operation at our institution over a 6year period from 2008
to 2014. We found the incidence of gastric leak to be 0.46% at our institution (3 out of 650 sleeve gastrectomies).
Our findings were consistent with reported incidences of gastric leaks, which have a variance of 04.3%.[10],[11]

Clinical presentation of gastric leaks after surgery

Clinically the presentation in this series varied from leaks presenting early with sepsis, haemodynamic instability, and
multiple organ failure to late presentations as perisleeve abscesses and chronic fistulas. This varied time and type of
presentation were similar to that reported in the literature.[9],[12] A majority of the leaks occurred after patient
discharge. Hence, these clinical presentations should lead to a high index of suspicion and to an early workup to rule
out leaks. If not recognised early and treated promptly, leaks can be a cause of prolonged morbidity as in the cases
referred to us from outside and sometimes even mortality.

Detection of clinically suspected gastric leaks after surgery

A high clinical suspicion for a gastric leak should be immediately followed up with a CECT scan. As was our experience
in two cases (cases 3 and 5), ultrasound imaging could not detect abnormalities perhaps because of obesity and the
small size of walledoff collections with a subdiaphragmatic, retrogastric location. A CECT will differentiate localized
leaks from diffuse spread and identify abscesses or fistulous tracts. As noted in this series, a leak of contrast material
at CECT may or may not be identified. Absence of leak of contrast commonly occurs in early leaks probably because
of temporary sealing off of the leak in the acute setting. This perhaps is the reason why gastrografin swallow tests
performed in patients with a clinically suspected leak are commonly false negative.[13],[14],[15]

Endoscopy if performed early in the postoperative period should be done with minimal insufflation. A fistulous opening
may be identified just beyond the oesophagogastric junction. The site and size of the leak are noted and the
suitability for stenting can be assessed if an oesophageal selfexpanding metallic stenting is contemplated. A fistulous
opening may not always be identified. At surgical reexploration, an obvious fistulous opening may be identified.
However, intraoperative identification and localisation of the site of leak may not be possible in some cases. We have
noted that an air leak test, if performed, also could be negative. We do not know if the use of methylene blue might
have been a better option as we do not routinely use this method. A methylene blue test may however, stain tissues
and surrounding structures thereby making identification and resuturing difficult. If the fistulous opening is identified
endoscopically as suggested by Baltazar et al., a guidewire passed through the fistula tract preoperatively and left in
place may help the surgeon find the defect on the gastric wall at reexploration although we did not have any
personal experience in this regard.[16] In some cases even when no fistulous opening is identified, the area along the
staple line just beyond the oesophagogastric junction should be resleeved or the suture reinforced (as in case 4) to
avoid missed leaks, which in a majority of the cases are present just beyond the oesophagogastric junction (as in
cases 2 and 3).


Management options

The four key principles in managing a patient with a gastric leak are adequate drainage, closure of the fistula,
decompression of the stomach and maintenance of nutrition.

Drainage of intraabdominal collections

Adequate drainage together with broadspectrum antibiotics is the first priority in the management of gastric leaks. If
a drain is placed intraoperatively, it should be retained or if the leak occurred later in the course of management;
patients may need immediate reoperation with peritoneal lavage and drainage. Imageguided pigtail drainage may
not be a feasible option considering the location of the abscess as described previously.[15] Also, in our opinion as
collections are perisleeve mostly retrogastric, subdiaphragmatic and loculated, surgical drainage may be the best
option. Many series have however, reported the successful use of pigtail drainage in these patients considering it a
good option in contained leaks.[17]

Surgical closure of the fistula

At reexploration if contamination is localized, an attempt at closing the site of leak is performed if the local tissues
are healthy.[9] If possible, resleeve of the fistula site by stapling can be performed with suture reinforcement. If this
is not possible, the fistula site is directly sutured close. This is performed in those who have localized collections and
in whom the tissues are healthy. Generalized peritonitis with haemodynamic instability is uncommon but if present,
an immediate surgical repair of the fistula site may be deferred for later.

Surgical decompression of the stomach

Sleeves constitute areas of high pressure. Mean intragastric pressure when filled with saline was 43 ± 8 mmHg in a
sleeved stomach versus 34 ± 6 mmHg in a normal stomach.[18] In our opinion, this high intragastric pressure is
why sleeve leaks tend to be prolonged and sutured closures commonly fail. This is also the quoted as a reason why
LSG has a higher leak rate than patients undergoing anastomotic techniques such as gastric bypass.[9] Although
controversial, this is the reason why we recommend conversion of the sleeve into a RouxenY gastric bypass in
addition to fistula repair to aid healing, as was performed in one patient with an acute and another with a chronic
fistula (case 3 and 5). It has been suggested that a Roux limb allows better drainage than a sleeve, which can have
possible functional disorders or stenotic areas.[16] This may not be advisable in the initial sitting if there is
generalised peritonitis. In the patient with acute leak in this series, this was performed after a period of waiting after
a laparoscopic drainage.

A fistula Roux may be performed in case of distal strictures wherein the edges of the gastric opening are freshened
and widened and a sidetoside anastomosis is performed (case 2). A sidetoside anastomosis is preferred as
rotation of the RouxenY loop will be less likely.[16] However, this procedure was originally described as a successful
option for any leak and may possibly be used instead of conversion of a sleeve into a RouxenY bypass.[16] We do
not recommend a fistula loop jujenostomy as it does not divert the bile flow and can make the fistula complex.

Endoscopic exclusion of the fistula

An oesophageal covered flexible selfexpanding metallic stent (Beta stent) designed especially for sleeve leaks can be
used to exclude the site of leak if it is small and present just beyond oesophagogastric junction (case 3). Success
rate of stenting is reported to be 5084% in the treatment of acute leaks and chronic fistulas but with 60% chance of
stent migration.[19] These stents can be used complementary to surgical fistula repairs as was done in the same
patient in this series (case 3). Few series also report successful secondary closures with complementary use of
stenting after surgical repair.[20]

The longer covered selfexpanding metallic oesophageal stent also specifically designed for postsleeve leaks (Mega
stent) may also be used (cases 1 and 5). In this stent the upper side of the stent is located near the middle of the
oesophagus, and the distal part of the stent is located in the antrum or in the first part of duodenum. As this stent is
placed across the pylorus, it may also possibly play a role in decompression of the stomach at the same time. An
advantage is that displacement of the stent is uncommon because of its length.[21] Another major advantage is that
feeds can be continued orally and need not be interrupted. However, bleeding may be a possibility due to pressure as
was seen in one patient in this series (case 2). We removed both types of stents uneventfully at 68 weeks.

Nutrition

Maintenance of nutrition is an important aspect that needs to be addressed in patients with sleeve leaks. In case oral
feeding is restricted, nutrition is maintained by a feeding jejunostomy or nasojejunal feeding or parenteral hyper
alimentation. In cases where a fullycovered, long, selfexpanding metal stent (Mega stent) is used, oral intake can
be continued as the long stent completely diverts entry into the stomach.

Sequence of procedures

A possible treatment algorithm is suggested in [Figure 5].{Figure 5}

In this series, use of surgical closure by suturing or stapling with decompression of the stomach and/or exclusion of
the fistula by stenting does not completely lead to resolution of the leak but reduces the volume and reduces the time
taken for closure of the fistula. The option of expectant management after only wide drainage is also a possibility but
in our experience in two patients referred from outside hospitals, this usually leads to a prolonged course with high
morbidity with nonhealing probably related to the fact that the sleeve is a high pressure zone.

Conclusion

To summarise, clinical suspicion and CECT scan constitute the mainstay for the diagnosis of sleeve leaks. Leakage
closure time may be shorter with early surgical and/or endoscopic intervention than expectant management.
Sequence and choice of endoscopic oesophageal stenting and/or surgical reintervention should be individualized
according to clinical presentation. A combination of methods depending on the situation is often required to achieve
success.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.
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Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy For Morbid Obesity: A Tertiary Care Experience and Design of A Management Algorithm

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Management of Gastric Leaks After Laparoscopic Sleeve Gastrectomy For Morbid Obesity: A Tertiary Care Experience and Design of A Management Algorithm

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5/16/2019 Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and

ence and design of a management algorith…

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